Device and method for generating forward directed shock waves

ABSTRACT

Described herein is a shock wave device for the treatment of vascular occlusions. The shock wave device includes an outer covering and an inner member inner connected at a distal end of the device. First and second conductive wires extend along the length of the device within the volume between the outer covering and the inner member. A conductive emitter band circumscribes the ends of the first and second wires to form a first spark gap between the end of the first wire and the emitter band and a second spark gap between the end of the second wire and the emitter band. When the volume is filled with conductive fluid and a high voltage pulse is applied across the first and second wires, first and second shock waves can be initiated from the first and second spark gaps.

PRIORITY

This application claims priority to provisional application Ser. No.62/521,994, filed Jun. 19, 2017, the entire disclosure of which isincorporated by reference.

FIELD

The present disclosure relates generally to the generation of shockwaves, and, more specifically, to the generation of shock waves withinvascular or urinary structures.

BACKGROUND

The subject invention relates to treating calcified lesions in bloodvessels, or obstructions in other vessels, such as kidney stones inureters. One common approach to addressing this issue is balloonangioplasty. In this type of procedure, a catheter, carrying a balloon,is advanced into the vasculature along a guide wire until the balloon isaligned with the occlusion. The balloon is then pressurized in a mannerto reduce or break the occlusion. When inflated to high pressures,angioplasty balloons can have a specific maximum diameter to which theywill expand. Generally, the opening in the vessel under a concentriclesion will typically be much smaller. As the pressure is increased toopen the passage way for blood flow, the balloon will be confined to thesize of the opening in the calcified lesion (before it is broken open).As the pressure builds, a tremendous amount of energy is stored in theballoon until the calcified lesion breaks or cracks. That energy is thenreleased and results in the rapid expansion of the balloon to itsmaximum dimension and may stress and injure the vessel walls.

Recently, the assignee herein has developed a system and method forbreaking up calcium deposits in, for example, arteries and veins. Such asystem is described, for example in U.S. Pat. Nos. 8,956,371 and8,888,788, both of which are incorporated herein by reference.Embodiments described therein include a catheter having balloon, such asan angioplasty balloon, at the distal end thereof arranged to beinflated with a fluid. Disposed within the balloon is a shock wavegenerator that may take the form of, for example, a pair of electrodes,which are coupled to a high voltage source at the proximal end of thecatheter through a connector. When the balloon is placed adjacent acalcified region of a vein or artery and a high voltage pulse is appliedacross the electrodes, a shock wave is formed that propagates throughthe fluid and impinges upon the wall of the balloon and the calcifiedregion. Repeated pulses break up the calcium without damagingsurrounding soft tissue. A similar technique can be used to treat kidneystones in the ureter. The shock waves generated by such systemstypically propagate in all directions from the electrodes.

Arteries are sometimes totally occluded with a thrombus, plaque, fibrousplaque, and/or calcium deposits. When this condition is present, thephysician typically first passes a soft narrow guide wire down theartery and through the occluded area. The guide wire may be as small as0.014 inches in diameter and usually has a soft flexible tip to helpavoid penetrating the artery wall in artery corners. The angioplastyballoon is then fed down the artery on the guide wire to the desiredlocation of the blockage. Unfortunately, many times the physician isfaced with a chronic occlusion which is not passable with a guide wire.This occurs when the occlusion is so tight and solid that the soft guidewire cannot penetrate through it. Stiffer guide wires may be used inthese cases, but they must be used very carefully because they caneasily penetrate the artery wall when forced against the chronic totalocclusion.

Guide wires have been proposed that utilize radio frequency energy toopen the occlusion. Unfortunately, the heat generated by the radiofrequency energy to open the occlusion is intense and can damage thewalls of the artery or vessel. The radio frequency energy produces aplasma which burns anything in its path. Hence, such systems must beused carefully and must be continuously moved without pause to avoidartery or vessel damage. Moreover, such an approach requires a centeringmechanism that keeps the plasma centered in the artery or vessel. Suchcentering is difficult to achieve, especially in the corners and bendsof the arteries or veins.

More recently, the assignee herein has proposed providing an electrodeon the tip of a guide wire for generating forward directed shock wavesto open a total occlusion enough to permit a guide wire and angioplastyballoon to be fed there through. In addition, such system avoids damageto the artery or vessel. This approach is disclosed in U.S. PatentPublication No. 2015/0320432, also incorporated herein by reference.

The subject invention relates to yet another alternative approach forgenerating forward directed shock waves that can be integrated with anangioplasty balloon. This approach can also be used in conjunction withother types of shock wave electrodes.

BRIEF SUMMARY

Described herein are shock wave devices and methods for the treatment ofplaques or obstructions in vessels. The vessels may include bloodvessels in a patient's vascular system or ureters in the patient'surinary system. One example of a shock wave device includes an outercovering and an inner member forming a guide wire lumen. The outercovering and inner member are connected at a distal end of the device,and a volume between the outer covering and the inner member is fillablewith a conductive fluid. A first conductive wire and a second conductivewire extend along the length of the device within the volume between theouter covering and the inner member and end proximate to the distal endof the device. The lengths of the first and second wires are insulatedand the ends of the first and second wires are uninsulated. A conductiveemitter band circumscribes the ends of the first and second wires andforms a first spark gap between the end of the first wire and theemitter band and a second spark gap between the end of the second wireand the emitter band. When the volume is filled with the conductivefluid and a high voltage pulse is applied across the first and secondwires, first and second shock waves will be initiated from the first andsecond spark gaps.

In some examples, the device further includes an insulting sheathcircumscribing the inner member in a region proximate to the ends of thefirst and second wires. In some variations, the outer covering comprisesan angioplasty balloon. In some examples, the emitter band is acylindrical tube that extends closer to the distal end of the devicethan the first and second wires. In some examples, the device furtherincludes a fluid pump connected to a proximal end of the deviceconfigured to provide conductive fluid to the volume between the outercovering and the inner member, and a fluid return line having an inletproximate to the distal end of the device and configured to remove theconductive fluid from the volume between the outer covering and theinner member. The fluid pump and fluid return line may be configured tocirculate the conductive fluid under pressure within the volume betweenthe outer covering and the inner member. In some examples, the devicefurther includes a pressure relief valve at an outlet of the fluidreturn line.

In some examples, the device further includes a third conductive wireand a fourth conductive wire extending along the length of the devicewithin the volume between the outer covering and the inner member andending proximate to the distal end of the device. The lengths of thethird and fourth wires may be insulated and the ends of the third andfourth wires may be uninsulated. The conductive emitter band maycircumscribe the ends of the third and fourth wires and form a thirdspark gap between the end of the third wire and the emitter band and afourth spark gap between the end of the fourth wire and the emitterband. When the volume is filled with the conductive fluid and a secondhigh voltage pulse is applied across the third and fourth wires, thirdand fourth shock waves may be initiated from the third and fourth sparkgaps. In some examples, the conductive fluid comprises saline or acombination of saline and a contrasting agent. In some examples, thedevice further includes one or more secondary emitter bands disposed ata medial location of the device and configured to initiate at least athird shock wave from the medial location.

One example of a method includes introducing a shock wave device into avessel, advancing the shock wave device within the vessel such that adistal end of the shock wave device faces a first treatment region, andapplying a high voltage pulse across first and second wires to initiatefirst and second shock waves from first and second spark gaps formedbetween the first and second wires and an emitter band. The positioningof the first and second wires and the emitter band results in the firstand second shock waves propagating in a substantially forward direction.

In some examples, the method further includes, after the applying step,advancing the shock wave device further within the vessel such that anangioplasty balloon is aligned with the first treatment region or secondtreatment region, and inflating the angioplasty balloon. In someexamples, the method further includes, after the applying step,advancing the shock wave device further within the vessel such that oneor more secondary emitter bands at a medial location of the device arealigned with the first treatment region or a second treatment region,and initiating third shock waves from the secondary emitter bands. Insome examples, the vessel is a blood vessel of a patient's vascularsystem or a ureter of the patient's urinary system. In some examples,first treatment region includes a chronic total occlusion (CTO),circumferential calcium, or a kidney stone.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 depicts a cutaway perspective view of an example shock wavedevice for generating forward directed shock waves, in accordance withsome embodiments.

FIG. 2 depicts a side sectional view of an example shock wave device forgenerating forward directed shock waves, in accordance with someembodiments.

FIG. 3 depicts a front sectional view of an example shock wave devicefor generating forward directed shock waves, in accordance with someembodiments.

FIG. 4 depicts an extended side sectional view of an example shock wavedevice for generating forward directed shock waves, in accordance withsome embodiments.

FIG. 5 depicts a side view of an extended length of an example shockwave device, in accordance with some embodiments.

FIG. 6 is a flowchart representation of an exemplary method forgenerating forward directed shock waves.

DETAILED DESCRIPTION

Described herein are devices, systems, and methods for generating shockwaves that propagate in a substantially forward direction to treatvascular diseases, such as chronic total occlusion (CTO) orcircumferential calcium, or to treat urinary diseases, such asconcretions or kidney stones in the ureter. In accordance with thepresent disclosure, a shock wave device includes an outer covering andan inner member forming a guide wire lumen. The outer covering and innermember are connected at a distal end of the device. A first conductivewire and a second conductive wire extend along the length of the devicewithin the volume between the outer covering and the inner member, andend proximate to the distal end of the device. A conductive emitter bandcircumscribes the ends of the first and second wires to form a firstspark gap between the end of the first wire and the emitter band and asecond spark gap between the end of the second wire and the emitterband.

When the volume is filled with conductive fluid (e.g., saline and/orimaging contrast agent) and a high voltage pulse is applied across thefirst and second wires, first and second shock waves can be initiatedfrom the first and second spark gaps. The voltage may range from 100 to10,000 volts for various pulse durations. This high voltage may generatea gas bubble at the end surface of a wire and cause a plasma arc ofelectric current to traverse the bubble to the emitter band and create arapidly expanding and collapsing bubble, which in turn creates amechanical shock wave at the distal end of the device. The positioningof the emitter band in relation to the end of the wire may result in theshock wave propagating out in a substantially forward direction towardthe distal end of the device. The shock waves may be mechanicallyconducted through the conductive fluid and through the outer covering inthe substantially forward direction to apply mechanical force orpressure to impinge on an occlusion or calcium facing the distal end ofthe device. The size, rate of expansion and collapse of the bubble (andtherefore, the magnitude, duration, and distribution of the mechanicalforce) may vary based on the magnitude and duration of the voltagepulse, as well as the distance between the end of the wire and theemitter band. The emitter band may be made of materials that canwithstand high voltage levels and intense mechanical forces (e.g., about1000-2000 psi or 68-136 ATM in a few microseconds) that are generatedduring use. For example, the emitter band may be made of stainlesssteel, tungsten, nickel, iron, steel, and the like.

FIG. 1 depicts a cutaway perspective view of an example shock wavedevice 100 for generating forward directed shock waves, in accordancewith some embodiments. The device 100 includes an outer covering 102(e.g., a flexible outer tube) and an inner member 104 that forms a lumenfor a guide wire 114. The outer covering 102 and inner member 104 areconnected at a distal end of the device 100, where the guide wire 114may exit the device 100. The interior volume of the device 100 betweenthe outer covering 102 and inner member 104 may be filled with aconductive fluid (e.g., saline and/or imaging contrast agent). Twoinsulated conductive wires 106 (e.g., insulated copper wires) extendalong the length of the device 100 within the interior volume. Whileonly one wire 106 is visible in FIG. 1, the second wire 106 extendsalong an opposing side of the inner member 104, as shown in FIGS. 2-3.The two wires 106 end near the distal end of the device 100 where theguide wire exits the lumen formed by the inner member 104. The ends ofthe two wires 106 include uninsulated portions (not shown). For example,the flat circular surfaces at the ends of the two wires may beuninsulated. An emitter band 108 is positioned within the interiorvolume around the ends of the two wires 106. The emitter band 108 may bea conductive cylinder with a diameter larger than the total diameter ofthe inner member 104 and the two wires 106 combined, such that theemitter band circumscribes the ends of the two wires 106 withoutcontacting the wires, as shown in FIG. 2. An insulating sheath 110(e.g., a polyimide insulator) may be positioned around the inner member104 to separate the two wires 106 from the inner member 104 and tofurther insulate the two wires 106 from one another. In this way, thepreferred conductive path between the two wires 106 is through theemitter band 108. When a high voltage pulse is applied across the twowires 106, an electrical current will arc from the uninsulated end ofone wire to the emitter band 108, and then arc again from the emitterband 108 to the uninsulated end of the other wire. As a result, shockwaves are initiated at the distal end of the shock wave device 100,which then propagate through the conductive fluid and the wall of theouter covering 102 to impinge on an occlusion or calcification.

In some embodiments, the device 100 may include a second pair of wires(not shown) offset from wires 106 by 90 degrees. For example, if wires106 are positioned at 0 and 180 degrees, the second pair of wires may bepositioned at 90 and 270 degrees. The second pair of wires also end nearthe distal end of the device 100 and include uninsulated portions attheir ends. The emitter band 108 circumscribes the ends of the secondpair of wires as well. A separate high voltage pulse may be appliedacross the second pair of wires to generate a second pair of arcs withthe emitter band 108. As a result, a second set of shock waves areinitiated from the distal end of the device 100. The first pair of wires106 and the second pair of wires may be activated alternately, which mayimprove the effectiveness of the device 100 by further spreading theshock waves.

A fluid return line 112 with an inlet near the distal end of the device100 draws in the conductive fluid from the interior volume, while afluid pump (not shown) pumps in additional conductive fluid via a fluidinlet (shown in FIG. 5) at a proximal end of the device 100. In thisway, the fluid return line 112 and fluid pump circulate the conductivefluid under pressure within the interior volume. Circulation of theconductive fluid may prevent bubbles created by the device 100 frombecoming trapped within the distal tip of the device 100 due to thelimited space within the tip. Furthermore, circulation of the conductivefluid may aid in cooling the device 100 and treatment site.

FIG. 2 depicts a side sectional view of an example shock wave device 100for generating forward directed shock waves, in accordance with someembodiments. As shown in FIG. 2, the two conductive wires 106 (e.g.,polyimide-insulated copper wires) are positioned along opposing sides ofthe inner member 104. Each of the wires 106 include uninsulated wireends 202. The insulating sheath 110 (e.g., polyimide tubing) ispositioned in a region proximate to the uninsulated wire ends 202 todecrease the likelihood of electrical current arcing from one wire endto the other. The emitter band 108 is positioned with a forward edgecloser to the distal end of the device 100 than the wire ends 202, suchthat two spark gaps are formed between each of the wire ends 202 and theemitter band 108. The positioning of the wire ends 202, insulatingsheath 110, and emitter band 108 makes it so that when a high voltagepulse is applied across the two wires 106, an electrical current willarc from the uninsulated end of one wire to the emitter band 108, andthen arc again from the emitter band 108 to the uninsulated end of theother wire. As a result, shock waves are initiated at the distal end ofthe shock wave device 100, which then propagate through the conductivefluid and the wall of the outer covering 102 to impinge on an occlusionor calcification. The positioning of the emitter band 108 closer to thedistal end of the device than the wire ends 202 helps to encourage theshock waves to propagate in a substantially forward direction (e.g.,longitudinally out of the distal end of the device 100). Shock waves maybe generated repeatedly, as may be desirable by the practitioner totreat a region of vasculature.

FIG. 3 depicts a front sectional view of an example shock wave device100 for generating forward directed shock waves, in accordance with someembodiments. As shown in FIG. 3, the emitter band 108 circumscribes thetwo conductive wires 106 (e.g., insulated copper wires) and the fluidreturn line 112. The fluid return line 112 includes an inlet that drawsin conductive fluid from the interior volume of the device to allow theconductive fluid to be circulated within the distal end of the device100.

FIG. 4 depicts an extended side sectional view of an example shock wavedevice 100 for generating forward directed shock waves, in accordancewith some embodiments. As shown in FIG. 4, in some embodiments, theouter covering of the device 100 includes an angioplasty balloon 402.The balloon 402 may be inflated by pumping additional fluid into theinterior volume of the device. The balloon 402 may be inflated before orafter applying shock waves to a treatment region. For example, in someembodiments, after forward directed shock waves are initiated using theemitter band 108 at the distal end of the device 100 to break apart anocclusion, the device 100 is advanced further into a patient's vascular,and the balloon 402 is inflated in the region of the occlusion tofurther treat the region.

In some embodiments, the shock wave device 100 may include secondaryemitter bands 404 located in a medial location of the device 100. Thedevice 100 shown in FIG. 4 includes two secondary emitter bands 404, butvarious numbers of secondary bands 404 may be used. For example, in someembodiments, the device 100 may include a single secondary emitter band404. In other embodiments, the device 100 may include five or moresecondary emitter bands 404. The secondary emitter bands 404 maygenerate shock waves using a variety of techniques. For example, thesecondary emitter bands 404 may generate shock waves using low-profileor coplanar electrodes, such as those described in U.S. Pat. No.8,888,788 and U.S. application Ser. No. 15/346,132, which are herebyincorporated by reference in their entireties. The shock waves mayradiate in a substantially radial direction from the medial location ofthe secondary emitter bands 404. In some embodiments, the secondaryemitter bands 404 may initiate shock waves independently of the emitterband 108 at the distal end of the device 100. For example, in someembodiments, after forward directed shock waves are initiated using theemitter band 108 at the distal end of the device 100 to break apart anocclusion, the device 100 is advanced further into a patient's vascularuntil the medial location of a secondary emitter band 404 is alignedwith the region of the occlusion. Then additional shock waves may beinitiated from the secondary emitter band 404 to further treat theregion. In order to permit independent operation, additional conductivewires may be provided between the high voltage source and the secondemitter bands 404.

In some embodiments, forward directed shock waves from the emitter band108, radial directed shock waves from the secondary emitter bands 404,and inflation of the angioplasty balloon 402 may be utilized in varioussequences and combinations to treat plaques or obstructions in vessels.The vessels may include blood vessels in a patient's vascular system orureters in the patient's urinary system.

FIG. 5 depicts a side view of an extended length of an example shockwave device 100, in accordance with some embodiments. The shock wavedevice 100 may be in communication with a fluid source and fluid pump(not shown) that introduces conductive fluid into an interior volume ofthe device 100 via a fluid inlet 502. The fluid pump may fill theinterior volume with fluid to a certain pressure. The conductive fluidmay be circulated within the interior volume of the device 100 bydrawing fluid into the fluid return line shown in FIGS. 1 and 3, andthen dispelling it through a waste outlet 504. The waste outlet 504 mayinclude a pressure relief valve to maintain the fluid pressure withinthe interior volume of the device while the conductive fluid iscirculated. Circulation of the conductive fluid may prevent bubblescreated by the device 100 from becoming trapped within the distal tip ofthe device 100 due to the limited space within the tip. Trapped bubblesmay block subsequent shock waves from propagating from the device 100,thus it is beneficial to prevent their build-up. In some embodiments,the waste outlet 504 may be connected to the fluid source so that thefluid pump recirculates the waste fluid.

FIG. 6 is a flowchart representation of an exemplary method forgenerating forward directed shock waves. As depicted in FIG. 6, a shockwave device is introduced into a vessel (602). The vessel may includeblood vessels in a patient's vascular system or ureters in the patient'surinary system. The shock wave device may be the device 100 described inreference to FIGS. 1-5. The shock wave device is advanced within thevessel such that a distal end of the device faces a first treatmentregion (604). The first treatment region may include a chronic totalocclusion (CTO), circumferential calcium, a kidney stone, or otherobstructions or concretions. Once the distal end of the shock wavedevice is facing the first treatment region, a high voltage pulse isapplied across first and second wires to initiate first and second shockwaves from first and second spark gaps formed between the first andsecond wires and an emitter band (606). Due to the positioning of thefirst and second wires and the emitter band, the first and second shockwaves propagate in a substantially forward direction out of the shockwave device to impinge on the occlusion or calcium in the firsttreatment area. In some embodiments, the shock wave device may then beadvanced further within the vessel such that an angioplasty balloon isaligned with the first treatment region or with a second treatmentregion (608). The angioplasty balloon may then be inflated in the firstor second treatment regions (610). In this way, conventional angioplastyballoon treatments may be applied to treat one or more treatment regionsafter the shock wave treatments are applied. Alternatively or inaddition, in some embodiments, the shock wave device may be advancedfurther within the vessel such that a secondary emitter band at a mediallocation of the device is aligned with the first treatment region orwith a second treatment region (612). Third shock waves may then beinitiated from the secondary emitter band to apply additional shock wavetreatment to the first or second treatment areas (614). Steps 604-614may be carried out in various sequences or combinations, and repeated asnecessary, when appropriate to treat the patient.

While this invention has been particularly shown and described withreferences to embodiments thereof, it will be understood by thoseskilled in the art that various changes in form and details may be madetherein without departing from the scope of the invention. For all ofthe embodiments described above, the steps of the methods need not beperformed sequentially.

What is claimed is:
 1. A shock wave device, comprising: an outercovering; an inner member, wherein the outer covering and inner memberare connected at a distal end of the device, and wherein a volumebetween the outer covering and the inner member is fillable with aconductive fluid; a first conductive wire and a second conductive wireextending along the length of the device within the volume between theouter covering and the inner member and ending proximate to the distalend of the device, wherein the lengths of the first and second wires areinsulated and wherein there is an uninsulated portion on each of thefirst and second wires near the distal end thereof; and a conductiveemitter band circumscribing the ends of the first and second wires andforming a first spark gap between the end of the first wire and theemitter band and a second spark gap between the end of the second wireand the emitter band, wherein when the volume is filled with theconductive fluid and a high voltage pulse is applied across the firstand second wires, first and second shock waves will be initiated fromthe first and second spark gaps.
 2. The device of claim 1, furthercomprising: an insulting sheath circumscribing the inner member in aregion proximate to the ends of the first and second wires.
 3. Thedevice of claim 1, wherein the outer covering comprises an angioplastyballoon.
 4. The device of claim 1, wherein the emitter band is acylindrical tube that extends closer to the distal end of the devicethan the ends of first and second wires.
 5. The device of claim 1,further comprising: a fluid pump connected to a proximal end of thedevice configured to provide conductive fluid to the volume between theouter covering and the inner member; and a fluid return line having aninlet proximate to the distal end of the device and configured to removethe conductive fluid from the volume between the outer covering and theinner member, wherein the fluid pump and fluid return line areconfigured to circulate the conductive fluid under pressure within thevolume between the outer covering and the inner member.
 6. The device ofclaim 5, further comprising: a pressure relief valve at an outlet of thefluid return line.
 7. The device of claim 1, further comprising: a thirdconductive wire and a fourth conductive wire extending along the lengthof the device within the volume between the outer covering and the innermember and ending proximate to the distal end of the device, wherein thelengths of the third and fourth wires are insulated and wherein there isan uninsulated portion on each of the third and fourth wires near thedistal end thereof; and wherein the conductive emitter bandcircumscribes the ends of the third and fourth wires and forms a thirdspark gap between the end of the third wire and the emitter band and afourth spark gap between the end of the fourth wire and the emitterband, wherein when the volume is filled with the conductive fluid and asecond high voltage pulse is applied across the third and fourth wires,third and fourth shock waves will be initiated from the third and fourthspark gaps.
 8. The device of claim 1, wherein the conductive fluidcomprises saline or a combination of saline and a contrasting agent. 9.The device of claim 1, further comprising: one or more secondary emitterbands disposed at a medial location of the device and configured toinitiate third shock waves from the medial location.
 10. The deviceclaim 1, wherein the inner member includes a guide wire lumen.
 11. Amethod for treating vascular plaques, comprising: introducing a shockwave device into a patient's vasculature, the shock wave devicecomprising: an outer covering; an inner member, wherein the outercovering and inner member are connected at a distal end of the device,and wherein a volume between the outer covering and the inner member isfilled with a conductive fluid; a first conductive wire and a secondconductive wire extending along the length of the device within thevolume between the outer covering and the inner member and endingproximate to the distal end of the device, wherein the lengths of thefirst and second wires are insulated and wherein there is an uninsulatedportion on each of the first and second wires near the distal endthereof; a conductive emitter band circumscribing the ends of the firstand second wires and forming a first spark gap between the end of thefirst wire and the emitter band and a second spark gap between the endof the second wire and the emitter band; advancing the shock wave devicewithin the vasculature such that the distal end of the shock wave devicefaces a first treatment region; and applying a high voltage pulse acrossthe first and second wires to initiate first and second shock waves fromthe first and second spark gaps.
 12. The method of claim 11, wherein theouter covering comprises an angioplasty balloon and the method furthercomprises: after the applying step, advancing the shock wave devicefurther within the vascular such that the angioplasty balloon is alignedwith the first treatment region; and inflating the angioplasty balloon.13. The method of claim 11, wherein the outer covering comprises anangioplasty balloon, the method further comprising: after the applyingstep, advancing the shock wave device further within the vascular suchthat the angioplasty balloon is aligned with a second treatment region;and inflating the angioplasty balloon.
 14. The method of claim 11,wherein the shock wave device further comprises one or more secondaryemitter bands disposed at a medial location of the device, the methodfurther comprising: after the applying step, advancing the shock wavedevice further within the vascular such that the medial location of theone or more secondary emitter bands is aligned with the first treatmentregion; and initiating third shock waves from the one or more secondaryemitter bands.
 15. The method of claim 11, wherein the shock wave devicefurther comprises one or more secondary emitter bands disposed at amedial location of the device, the method further comprising: after theapplying step, advancing the shock wave device further within thevascular such that the medial location of the one or more secondaryemitter bands is aligned with a second treatment region; and initiatingthird shock waves from the one or more secondary emitter bands.
 16. Themethod of claim 11, wherein the vessel is a blood vessel of a patient'svascular system or a ureter of the patient's urinary system.
 17. Themethod of claim 11, wherein first treatment region includes a chronictotal occlusion (CTO), circumferential calcium, or a kidney stone.